Академический Документы
Профессиональный Документы
Культура Документы
The first specialized gender identity clinic for children and adolescents in
the Netherlands opened its doors at the Utrecht University Medical Center
in 1987. The number of applicants was initially low: No more than a few
children and adolescents were referred to the clinic annually. In 2002, the
clinic moved to the VU University Medical Center in Amsterdam and is now
301
302 A. L. C. de Vries and P. T. Cohen-Kettenis
50
45
40
35
30
25
20
15
10
5
0
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
FIGURE 1 Referred children, Dutch Gender Identity Clinic, 1987–2011.
50
45
40
35
30
25
20
15
10
5
0
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
19
18
17
16
15 Age
14
13
12
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
FIGURE 3 Mean age of referred adolescents, 1987–2011.
dysphoria at an early age. A great deal has been accomplished in this field
in the past three decades. In addition to the increasing numbers of refer-
rals, the care for these gender dysphoric children and adolescents has also
experienced growth. Over the course of years, diagnostic protocols for chil-
dren under 12 years, as well as adolescents from 12 to 18 years, of age
have been constructed (Cohen-Kettenis & Pfäfflin, 2003; Delemarre-van de
Waal & Cohen-Kettenis, 2006), screening and diagnostic instruments have
been developed, and there are now specific approaches for both age groups.
These are not isolated developments: Outside of the Netherlands, even
more experience has been gained and knowledge has expanded in the field
of juvenile gender dysphoria. Various international treatment guidelines have
been developed (de Vries, Cohen-Kettenis, & Delemarre-van de Waal, 2007;
Di Ceglie, Sturge, & Sutton, 1998; Hembree et al., 2009; World Professional
Association of Transgender Health, WPATH, 2011).
Especially with regard to the clinical management of gender dysphoria
in adolescents, the Netherlands has pioneered and played a leading role
internationally. The “Dutch protocol” has become proverbial in this field.
Various publications have demonstrated the efficacy of parts of this approach
(Cohen-Kettenis & van Goozen, 1997; de Vries, 2010; de Vries, Steensma,
Doreleijers, & Cohen-Kettenis, 2010; Smith, van Goozen, & Cohen-Kettenis,
2001), although the protocol has also been subject to criticism (Korte et al.,
2008).
As a likely result of the professional and media attention to the Dutch
approach, there is an increasing clinical interest in the rationale and descrip-
tion of the ways gender dysphoria in children and adolescents is managed
in the Netherlands (Kreukels & Cohen-Kettenis, 2011). However, to date
such a description did not exist. In this article, we will, therefore, give an
account of our diagnostic and treatment protocols, which differ for children
304 A. L. C. de Vries and P. T. Cohen-Kettenis
CONTEXT
Etiology
No unequivocal etiological factor determining atypical gender development
has been found to date. The most extreme form of gender dysphoria, Gender
Identity Disorder (GID) in the current Diagnostic and Statistical Manual of
Mental Disorders (American Psychiatric Association, 2000) is most likely a
multifactorial condition in which psychosocial as well as biological aspects
play some role. In recent years, a great deal of attention has been paid to
biological theories (for an overview, see Meyer-Bahlburg, 2010), whereas
psychosocial factors used to be considered of primary importance in the
past. For instance, it was once theorized that GID was a symptom of certain
psychiatric disorders such as borderline personality (Lothstein, 1984) or psy-
chosis (a Campo, Nijman, Merckelbach, & Evers, 2003). Current studies on
psychopathology among adults with GID do not support either of these con-
clusions (e.g., Gomez-Gil, Vidal-Hagemeijer, & Salamero, 2008; Haraldsen &
Dahl, 2000; Smith, van Goozen, Kuiper, & Cohen-Kettenis, 2005).
However, the relationship between certain forms of psychopathology
and GID is still not entirely clear (Meyer-Bahlburg, 2010). In adults, elevated
psychopathology has been found in some studies (e.g., Bodlund, Kullgren,
Sundbom, & Hojerback, 1993; De Cuypere, Janes, & Rubens, 1995; Hepp,
Kraemer, Schnyder, Miller, & Delsignore, 2005). Research among children
and adolescents referred to gender identity clinics has demonstrated more
frequent (internalizing) psychopathology than observed in their peers from
the general population (Cohen-Kettenis, Owen, Kaijser, Bradley, & Zucker,
2003; de Vries, Doreleijers, Steensma, & Cohen-Kettenis, 2011; Di Ceglie,
Freedman, McPherson, & Richardson, 2002; Wallien, Swaab, & Cohen-
Kettenis, 2007; Zucker & Bradley, 1995; Zucker, Bradley, Owen-Anderson,
et al., 2010; Zucker, Owen, Bradley, & Ameeriar, 2002). One theory about
this relationship is that a predisposition to anxiety combined with parental
psychopathology in gender variant children can lead to full-blown GID
(Zucker & Bradley, 1995). Zucker and colleagues (Zucker, Bradley, Ben-Dat,
et al., 2003; Zucker, Bradley, & Lowry Sullivan, 1996) have found among chil-
dren referred to the Toronto gender identity clinic more separation anxiety
in the boys and more psychopathology in their mothers than in the gen-
eral population. At the Dutch gender identity clinic, some indications were
found for a predisposition to anxiety among the referred children (Wallien,
Swaab, et al., 2007; Wallien, van Goozen, & Cohen-Kettenis, 2007). However,
parental psychopathology was not demonstrated (Wallien, 2008).
Dutch Approach to Gender Dysphoria in Children and Adolescents 305
CHILDREN
Diagnosis
In the Amsterdam gender identity clinic, several sessions spread out over a
longer period of time are allotted to prepubertal children below age 12 for
diagnosis. This is done to gain insight into how the gender dysphoria devel-
ops over time. The children and their parents are seen at least once together,
each of the parents is interviewed individually, and the child is observed a
number of times and subjected to an extensive psychodiagnostic assessment.
The procedure is concluded with an advisory consultation.
One aim of the examination is to determine whether the criteria for
a GID diagnosis have been met. This can be rather simple with children
demonstrating an extreme degree of gender dysphoria or who are very
explicit in their desire for gender reassignment. However, the clinical picture
is not always that clear. Gender dysphoria is a dimensional phenomenon and
can exist to a greater or lesser degree. This is something to be taken into
greater account in DSM-5 (APA, for proposed revision see www.dsm5.org)
than is presently the case (Zucker, 2010). In addition, it can also manifest
itself in various ways. One child with a strong gender dysphoric feeling
may be very sensitive to his or her surroundings and only dares to come
out at certain times and under certain circumstances. In another child, we
can see very openly expressed gender dysphoria (Meyer-Bahlburg, 2002). In
other cases, a child can show gender variant behavior without suffering from
Dutch Approach to Gender Dysphoria in Children and Adolescents 307
actual gender dysphoria. In those cases, the reason for referral usually lies
more in the environment (e.g., parents struggling with their child’s behavior)
than in the child.
All kinds of aspects of the children’s functioning are subsequently eval-
uated, such as their cognitive level, psychosocial functioning, and scholastic
performance. For example, a boy may like playing with girls, not because
he is unhappy being a boy, but because he has difficulty joining in with
other boys of his age due to limited cognitive faculties and immaturity. Any
other possible psychopathology is dealt with extensively (Wallien, Swaab, &
Cohen-Kettenis, 2007). If any is found, the possible relationship between
the gender dysphoria and other diagnoses is investigated. In this way,
for example, one can investigate whether an autistic boy’s fascination for
fancy dresses and long hair is more part of his autism or whether his
autism reinforces certain aspects of his gender dysphoria (de Vries, Noens,
Cohen-Kettenis, van Berckelaer-Onnes, & Doreleijers, 2010). Some psychi-
atric diagnoses may be unrelated to the gender presentation but still need
attention (e.g., tic disorders). There are also problems or psychiatric disor-
ders that can arise as a consequence of the gender dysphoria (social anxiety,
depression, oppositional defiant disorders).
Furthermore, a good assessment of family functioning as well as the
role of the child’s gender variant behavior on family functioning is useful in
order to gain a complete clinical picture.
Treatment
The Dutch approach to clinical management of children with GID con-
tains elements of a therapeutic approach but is not directed at the gender
dysphoria itself. Instead, it focuses on its concomitant emotional and behav-
ioral and family problems that may or may not have an impact on the child’s
gender dysphoria.
PARENT COUNSELING
After the evaluation described above, the results of the assessment and diag-
nostic procedure are discussed with the parents (and partially with the child)
and an ensuing individual recommendation is given. For children in whom
no concomitant problems have been observed, who have sensitive parents
with an appropriate style of child rearing, advice aimed at dealing with the
gender dysphoria is sufficient. This sometimes results in more counseling at
a later point in time when the family again needs support or advice or finds it
increasingly difficult to deal with the uncertainties with regard to the child’s
psychosexual outcome. Because most gender dysphoric children will not
remain gender dysphoric through adolescence (Wallien & Cohen-Kettenis,
2008), we recommend that young children not yet make a complete social
308 A. L. C. de Vries and P. T. Cohen-Kettenis
understanding with their son that he only wears dresses at home. In such a
case, it is crucial that the parents give their child a clear explanation of why
they have made their choices and that this does not mean that they them-
selves do not accept the cross-dressing. The child will, thus, sometimes be
frustrated and learn that not all of one’s desires will be met. The latter is an
important lesson for any child, but even more so for children who will have
a gender reassignment later in life. Although hormones and surgery effec-
tively make the gender dysphoria disappear (Murad et al., 2010), someone’s
deepest desire or fantasy to have been born in the body of the other gender
will never be completely fulfilled.
The Amsterdam gender identity clinic does not provide any physical medical
interventions before puberty. Parents are advised to adopt an attitude of
watchful waiting. Not until the child arrives at puberty and is still gender
310 A. L. C. de Vries and P. T. Cohen-Kettenis
dysphoric will he or she be seen again in our gender identity clinic. Parents
and child are informed about this possibility.
ADOLESCENTS
Diagnosis
In nearly all cases seen, adolescents age 12 and up come to the Amsterdam
gender identity clinic with a desire for gender reassignment. While gender
dysphoric feelings in younger children will usually remit, in adolescents this
is rarely the case. Similar to the children, a diagnostic trajectory is initiated
that is spread out over a longer period of time. Here, too, there is an intake
session with the adolescents and their parents, followed by individual talks
with the parents and the youths and a psychodiagnostic assessment. Shortly
before the start of any physical medical treatment, adolescents will also
have a child psychiatric examination by a member of the team other than
the diagnostician and a medical screening by the pediatric endocrinologist.
Finally, a recommendation concludes the procedure. When an adolescent
is considered eligible for puberty suppression, the diagnostic trajectory is
extended, as the puberty suppression phase is still considered diagnostic.
This medical intervention puts a halt to the development of secondary sex
characteristics. It has been used for over 20 years now in the treatment of
precocious puberty and there is evidence that gonadal function is reactivated
soon after cessation of treatment (Mul & Hughes, 2008).
The Amsterdam gender identity clinic follows the international
Standards of Care of the World Professional Association for Transgender
Health (WPATH, 2011), which advises that the decision to undergo gender
reassignment be taken in several steps. In the Standards of Care, the diag-
nostic phase is followed by the real-life experience stage in which cross-sex
hormones are prescribed and, eventually, the subject can undergo gender
reassignment surgery.
In developing a rapport with adolescents and their parents, particu-
lar attention is paid to obtaining open and nonjudgmental contact with
the youths and their parents. Many elements of this are recognizable as
the developmental approach described by Di Ceglie (2009). In a number
of sessions, the diagnostician tries to gain a picture of the youth’s gen-
eral and psychosexual development. Information is gathered about current
functioning, individually, with peers and in the family. As to sexuality, the
subjective meaning of dressing up or the type of clothing, sexual experience,
sexual behavior and fantasies, sexual orientation and body perception are
discussed.
Adolescents are considered eligible for puberty suppression when they
are diagnosed with GID, live in a supportive environment and have no
serious psychosocial problems interfering with the diagnostic assessment
Dutch Approach to Gender Dysphoria in Children and Adolescents 311
Treatment
When it appears from the advisory consultation that there are concomitant
psychiatric or family problems, some form of psychological treatment will
be sought. This treatment is usually given close to the youth’s home rather
312 A. L. C. de Vries and P. T. Cohen-Kettenis
than at our clinic. Certainly, when the problems are destabilizing and there
is an insufficient guarantee that the youth is committed to the therapeutic
relationship necessary for a physical medical intervention, the treatment will
be postponed. In a study investigating the extent of psychiatric problems in
gender dysphoric adolescents, it appeared that the diagnostic stage in some
cases may take more than one and a half years before physical medical
intervention actually can begin (de Vries, Doreleijers, et al., 2011). This was
the case in about one third of the youths with a GID diagnosis. These youths
more frequently suffered from an oppositional defiant behavioral disorder
or more than three psychiatric diagnoses (in addition to the GID diagnosis)
compared with adolescents who were considered immediately eligible. They
also were less likely to live with both biological parents and on average had
a lower intelligence. Furthermore, they were, on average, older at the time of
referral (de Vries, Doreleijers, et al., 2011). Clearly, psychiatric problems were
not the only factor influencing the delay in starting puberty suppression.
However, for many of the gender dysphoric youths, there are no psy-
chological problems other than the gender dysphoria. Yet, these adolescents
do need good counseling. Some themes need repeatedly to be touched
upon, because they gain a new dimension as the adolescents grow older,
for example, dating when you have a body that has not yet been operated
on, or infertility. Regular contact with the psychologist is also necessary for
adequate preparation for the next treatment steps. An increasing problem
is that many adolescents do not realize that an unhealthy lifestyle (smok-
ing, obesity) has a negative influence on the treatment, surgery in particular.
In addition to a preparation for the future, some profit from a form of psy-
chotherapy. This may be because they are anxious, need to become more
assertive or feel insecure. For those who do not easily verbalize their con-
cerns, psychomotor therapy can be helpful to let them feel more at ease
with their bodies and to learn to talk more easily about their problems.
TRANSITIONING
Many gender dysphoric youths choose to begin living in the desired gender
role simultaneously with the beginning of puberty suppression. The ado-
lescents and their families are then supported in this process so that it can
be achieved successfully. Many youths also obtain help from Transvisie, the
only self-help organization working with trans youth in the Netherlands. It is,
however, not a requirement to begin with the real life experience as long as
cross-sex hormones are not taken.
a low voice and facial-and body hair growth (Delemarre-van de Waal &
Cohen-Kettenis, 2006).
In addition, new themes will be brought up in sessions. In this stage,
some of the youths will start going out with someone for the first time and
they will be more consciously dealing with dating, romantic relationships,
partner choice, careers, and having children. Because the operations
suddenly seem to be close at hand, the possibilities and limitations of the
gender reassignment surgery, about which they will gradually have to make
choices (e.g., various types of metaidoioplasty or phalloplasty, or no genital
surgery for trans boys), are once again discussed (Cohen-Kettenis, 2006).
Completely irreversible interventions. When the adolescent has come
of age at 18 and still meets all the eligibility criteria, he or she can be eligible
for the last step of the gender reassignment treatment trajectory, the gen-
der reassignment surgeries. Trans boys may undergo several operations: (if
they came relatively late to the clinic and already had some breast develop-
ment) mastectomy, hysterectomy or oovariectomy, and, if desired, genital
operations (metaidoioplasty or phalloplasty). Trans girls usually undergo
vaginoplasty and, if necessary, at their own financial expense, augmenta-
tion mammoplasty. Trans girls who began puberty suppression at a young
age often have insufficient penile skin for a classical vaginoplasty and need
an adjusted surgical procedure using colon tissue.
TREATMENT EVALUATION
gender dysphoric (de Vries, 2010). Many studies in gender dysphoric adults
have demonstrated that gender reassignment treatment is effective. These
initial results demonstrate that this is also the case in young people who
have received GnRHa to suppress puberty at an early age, followed by the
actual gender reassignment (de Vries, 2010).
The concern that early physical medical intervention has unfavorable
physical effects has to this date not been confirmed (Delemarre-van de
Waal & Cohen-Kettenis, 2006). Initial studies on, for example, bone devel-
opment and insulin sensitivity demonstrate favorable results (Schagen et al.,
in press; Vance, et al., in press).
REFERENCES
a Campo, J., Nijman, H., Merckelbach, H., & Evers, C. (2003). Psychiatric comorbidity
of gender identity disorders: a survey among Dutch psychiatrists. American
Journal of Psychiatry, 160, 1332–1336.
American Psychiatric Association. (2000). Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition, Text Revision. Washington, DC: Author.
www.dsm5.org
American Psychiatric Association. (in press). Diagnostic and statistical manual of
mental disorders (5th ed.). Washington, DC: Author.
Bartlett, N. H., Vasey, P. L., & Bukowski, W. M. (2000). Is gender identity disorder
in children a mental disorder? Sex Roles, 43, 753–785.
Berglund, H., Lindstrom, P., Dhejne-Helmy, C., & Savic, I. (2008). Male-to-female
transsexuals show sex-atypical hypothalamus activation when smelling odorous
steroids. Cerebral Cortex, 18, 1900–1908.
Bodlund, O., Kullgren, G., Sundbom, E., & Hojerback, T. (1993). Personality traits
and disorders among transsexuals. Acta Psychiatrica Scandinavica, 88(5),
322–327.
Carrillo, B., Gomez-Gil, E., Rametti, G., Junque, C., Gomez, A., Karadi, K., et al.
(2010) Cortical activation during mental rotation in male-to-female and female-
to-male transsexuals under hormonal treatment. Psychoneuroendocrinology,
35, 1213–1222.
Cohen-Kettenis, P. T. (2001). Gender identity disorder in DSM? Journal of the
American Academy of Child and Adolescent Psychiatry, 40, 391.
Cohen-Kettenis, P. T. (2006). Gender identity disorders. In C. Gillberg,
R. Harrington, & H.-C. Steinhausen (Eds.), A clinician’s handbook of child
and adolescent psychiatry (pp. 695–725). New York, NY: Cambridge University
Press.
Cohen-Kettenis, P. T., Delemarre-van de Waal, H. A., & Gooren, L. J. (2008).
The treatment of adolescent transsexuals: changing insights. Journal of Sexual
Medicine, 5, 1892–1897.
Cohen-Kettenis, P. T., Owen, A., Kaijser, V. G., Bradley, S. J., & Zucker, K. J. (2003).
Demographic characteristics, social competence, and behavior problems in chil-
dren with gender identity disorder: a cross-national, cross-clinic comparative
analysis. Journal of Abnormal Child Psychology, 31, 41–53.
Cohen-Kettenis, P. T., & Pfäfflin, F. (2003). Transgenderism and Intersexuality in
Childhood and Adolescence (Vol. 46). Thousand Oaks, CA: Sage.
Cohen-Kettenis, P. T., & van Goozen, S. H. (1997). Sex reassignment of adolescent
transsexuals: a follow-up study. Journal of the American Academy of Child and
Adolescent Psychiatry, 36, 263–271.
Coolidge, F. L., Thede, L. L., & Young, S. E. (2002). The heritability of gender identity
disorder in a child and adolescent twin sample. Behavior Genetics, 32, 251–257.
Crouter, A. C., Whiteman, S. D., McHale, S. M., & Osgood, D. W. (2007).
Development of gender attitude traditionality across middle childhood and
adolescence. Child Development, 78, 911–926.
De Cuypere, G., Janes, C., & Rubens, R. (1995). Psychosocial functioning of
transsexuals in Belgium. Acta Psychiatrica Scandinavica, 91, 180–184.
Dutch Approach to Gender Dysphoria in Children and Adolescents 317
Wallien, M. S., Veenstra, R., Kreukels, B. P., & Cohen-Kettenis, P. T. (2010). Peer
group status of gender dysphoric children: a sociometric study. Archives of
Sexual Behavior, 39, 553–560.
World Professional Association of Transgender Health (WPATH). (2011). Standards
of care. Seventh edition. Retrieved from http//www.wpath.org/
Yunger, J. L., Carver, P. R., & Perry, D. G. (2004). Does gender identity influence
children’s psychological well-being? Developmental Psychology, 40, 572–582.
Zhou, J. N., Hofman, M. A., Gooren, L. J., & Swaab, D. F. (1995). A sex difference
in the human brain and its relation to transsexuality. Nature, 378(6552), 68–70.
Zucker, K. J. (2006). Gender Identity Disorder. In D. A. Wolfe & E. J. Mash (Eds.),
Behavioral and emotional disorders in adolescents: Nature, assessment, and
treatment (pp. 535–562). New York, NY: Guilford.
Zucker, K. J. (2010). The DSM diagnostic criteria for gender identity disorder in
children. Archives of Sexual Behavior, 39, 477–498.
Zucker, K. J., & Bradley, S. (1995). Gender identity disorder and psychosexual
problems in children and adolescents. New York, NY: Guilford.
Zucker, K. J., Bradley, S. J., Ben-Dat, D. N., Ho, C., Johnson, L., & Owen, A. (2003).
Psychopathology in the parents of boys with gender identity disorder. Journal
of the American Academy of Child and Adolescent Psychiatry, 42, 2–4.
Zucker, K. J., Bradley, S. J., & Lowry Sullivan, C. B. (1996). Traits of separation
anxiety in boys with gender identity disorder. Journal of the American Academy
of Child and Adolescent Psychiatry, 35, 791–798.
Zucker, K., Bradley, S., Owen-Anderson, A., Singh, D., Blanchard, R., & Bain, J.
(2010). Puberty-blocking hormonal therapy for adolescents with gender identity
disorder: A descriptive clinical study. Journal of Gay & Lesbian Mental Health,
15(1), 58–82.
Zucker, K. J., Owen, A., Bradley, S. J., & Ameeriar, L. (2002). Gender-dysphoric
children and adolescents: A comparative analysis of demographic characteristics
and behavioral problems. Clinical Child Psychology and Psychiatry. 7, 398–411.